A FRAMEWORK FOR CAPTURING CLINICAL-DATA SETS FROM COMPUTERIZED SOURCES

The pressure to improve health care and provide better care at a lower cost has generated the need for efficient capture of clinical data. M any data sets are now being defined to analyze health care. Historical ly, review and research organizations have simply determined what data they wanted to collect, developed forms, and then gathered the inform ation through chart review without regard to what is already available institutionally in computerized databases. Today, much electronic pat ient information is available in operational data systems (for example , laboratory systems, pharmacy systems, and surgical scheduling system s) and is accessible by agencies and organizations through standards f or messages, codes, and encrypted electronic mail. Such agencies and o rganizations should define the elements of their data sets in terms of standardized operational data, and data producers should fully adopt these code and message standards. The Health Plan Employer Data and In formation Set and the Council of State and Territorial Epidemiologists in collaboration with the Centers for Disease Control and Prevention and the Association of State and Territorial Public Health Laboratory Directors provide examples of how this can be done.